1. Assessment of Renal and Urinary Tract Function (Chap. 43)

3. Functions of the Kidneys:
Urine formation
Excretion of water products
Regulation of electrolytes
Regulation of acid-base balance
Regulation of water balance
Control of blood pressure
Renal clearance ( the ability of the kidneys to clear solutes from the plasma
Regulation of red blood cell production
Synthesis of vit.D to active form
Secretion of prostaglandins (PGE2) ( vasodilatation effect and maintaining renal flow

4. Assessment: Health history Patient chief concern
Pain ( characteristic, location, duration,…. Etc)
Dysuria, Hesitancy, urine incontinence, urinary frequency, Hematuria, Nocturia, polyuria, oliguria (less than 400/day), and anuria ( urine less than 50 ml/day)
The present of renal calculi
History of GI symptoms
History of UTI

5. Cont… History of sexual transmitted disease
Habits: smoking, alcohol, drugs
Medication
History of any renal diagnostic test ( catheterization)
Any risk factors ( DM, Hypertension, Sickle cell anemia, Benign prostatic hypertrophy, spinal cord injury, immobilization

6. Physical examination

7. Diagnostic Evaluation:
Urine analysis: urine color (light yellow), Urine clarity ( clear and translucent), urine odor ( arometic), urine PH ( acidic: 6.0 or 4.6-8), urine specific gravity, detect protein, glucose and ketone bodies in the urine, microscopic examination of the urine sediments to detect RBC’s, WBC’s, casts, crystals, pus (pyuria), and bacteria
Urine Culture and sensitivity
Renal function test (KFT): Renal concentrate test (Specific gravity, and urine osmolarity) creatinine clearance test ( 24-hour urine collection test), serum creatinine, BUN, and serum electrolyte level

9. Continue X-Ray film and other Imaging modalities:
KUB studies: to detect size, shape, location and position of the kidneys, to reveal stone, hydronephrosis ( distention of the kidney pelvis), Cysts, tumors, and any surrounding tissue abnormalities.
CT scan and MRI: cross section view of the kidney and urinary tract: metal objects should be removed, sedative or certain contrasts may given, contraindicated in patient has pacemaker, surgical clips, or any metal objects

10. Cont…
3. General Ultrasonography: assess fluid accumulation, masses, congenital malformation, changes in size, shape, or any obstruction, fluid intake should be encouraged before the procedure
4. Bladder Ultrasonography: to measure fluid volume in the bladder, indicated for urinary frequency, inability to void after removal of FC or postoperative, measuring residual volume of urine after voiding

11. Cont….
Intravenous urography: intravenous pyelography (IVP) or intravenous urogram (IVU). History of iodine or any contrast allergy should be obtained before the procedure. Patient should be instructed he may have temporary feeling of wormth, flushing of the face and unusual flavor (seafood) in the mouth. Monitor the patient closely for any allergic reaction.

12. Cont.
6. Retrograde pyelography: catheter induced through ureters to the kidney pelvis by means of cystoscopy. Provide direct visualization of the kidney.
Cystography: direct visualization of the bladder walls. Assessing vesicoureteral reflux ( back flow of urine from the bladder to one or both of the ureters), bladder injury
8. Renal Angiography: provide an image of the renal arteries preparation done same as Cardiac cathetarization

13. 9. Urologic Endoscopic Procedure ( Endourology):
Cont……
9. Urologic Endoscopic Procedure ( Endourology):
through Cystoscope inserted via urethra or percataneously.
Direct visualization of the system,
removal of stone,
obtaining urine specimen from the kidney.
Sedation or anesthesia may performed, patient should be kept NPO.
Post- procedure:
moist heat to the lower abdomen and warm sitz bath are helpful in relieving pain and relaxing the muscles,
monitor the patient with prostatic hyperplasia for urine retention,
intermittent catheterization may needed for few hours
monitor for S/S of UTI, monitor for signs of retention

14. Cont… 10. Kidney biopsy: Indications: Unexplained acute renal failure,
persistent proteinuria or hematuria,
transplant rejection,
and glomerulopathies.
Contraindications:
Serious bleeding disorders,
excessive obesity, and sever hypertension.
It is usually performed percataneously with a biopsy needle

15. Procedure for kidney biopsy include:
Place patient in prone position with a sandbag under the abdomin
The skin site of biopsy is infiltrated with local anesthesia
The needle biopsy is inserted just inside the renal capsule
The patient is instructed to breath in and hold the breath to immobile the kidney during insertion of the needle
Nursing diagnosis for the patient undergoing assessment of urinary or renal function include the following:
Knowledge deficit regarding the procedure and diagnostic test
Acute pain related to renal invasive diagnostic procedure
Fear related to possible procedure or serious illness

16. Management of patients with Urinary Disorders
Chapter 44 & 45 ( )
Management of patients with Urinary Disorders

17. Dysfunctional Voiding pattern: (1578)
Urinary Retention:
Is the inability to empty the bladder completely during attempt to void. Residual urine is the urine remain in the bladder
Causes:
DM,
prostatic enlargement,
urethral pathology ( infection , tumor, calculus),
trauma,
pregnancy,
Neurological disorder,
some medication ( anti-cholinergic agent, tricyclic antidepressant, alpha-adrenergic, beta-adrenergic blockers, and estrogens .

18. Complication:
may lead to chronic infection which may lead to calculi formation,
polynephritis,
sepsis,
back flow of urine lead to deterioration of the kidney,
leakage of the urine may lead to peripheral skin damage

19. Nursing Management: Promote normal urinary elimination:
Provide privacy, ensure the environment and position is conducive to voiding, assisting the patient to use bathroom, and offering reassurance
Applying warmth to relax sphincter
Simple trigger techniques, such as turning on the water while voiding attempt, stroking the abd or inner thigh, tapping above the pubic area
After surgery the prescribed analgesia should be given

20. Cont…
Promote urinary elimination: Catheterization is used to prevent overdistention of the bladder
Promote home and community-based care:
Provide easy, safe access to the bathroom
Installing support bars in the bathroom
Placing a bedpan or urinal within easy reach
Leaving a light on the bedroom, and bathroom
Wearing clothing that is easy to remove

21. Chart 45-8 (Strategies for promoting Urinary Continence:

22. II. Urinary Incontinence:
Is the involuntary or uncontrolled loss of urine from the bladder
Types of Incontinence:
Stress incontinence: as a result of a sudden increase in intra-abdominal pressure (sneezing, coughing, or changing position
Urge Incontinence: associated with a strong urge to void that can not be suppressed.
predominantly medications

23. Cont…
3. Reflex incontinence: due to hyperflexia in the absence of normal sensation usually associated with voiding.
4. Overflow incontinence: due to overdistention of the bladder
5. Functional incontinence: lower urinary tract function is intact but other factors such as sever cognitive impairment, or physical impairment
6. Latrogenic incontinence: due to extrinsic medical factors,

24. Behavioral intervention:
Medical management:
Behavioral intervention:
Fluid management: encourage fluid intake of ml daily between breakfast and evening
Standardized voiding frequency: voiding on a schedule
Time voiding, promote voiding ( in patient has cognitive difficulties), Habit retraining, pelvic muscle exercise (PME) (Kegel exercise): to strengthen the voluntary muscles ( gently tightening the same muscle used to stop the stream of urine 5-10 sec. follow by 10 sec resting phase.

25. Cont… Pharmacological therapy:
Anticholinergic agents: (oxybutynin, dicyclomic) which inhibit bladder contraction, first line medication for urge incontinence
Tricyclic antidepressant (impramine): decrease bladder contraction as well as strengthen bladder neck resistance
Estrogen: restoring the mucosal integrity, vascular, and muscular integrity of the urethra
III.Surgical management: surgical correction of the bladder and urethra if the patient not responding to the previous management

26. III. Neurogenic Bladder:
Is a dysfunction of the bladder due to a lesion of the nervous system caused by spinal injury, spinal tumor, herniated vertebral disk, multiple sclerosis, infection, congenital anomalies, and DM.
Pathophysiology:
Spastic (or reflex) bladder: is the most common type and is caused by any spinal cord injury above the voiding reflex arc ( Upper motor neuron lesion).
The result is a loss of conscious sensation and cerebral motor control.
A spastic bladder empties on reflex, with minimal or no controlling influence to regulate its activity

27. Cont..
2. Flaccid bladder: caused by lower motor neuron lesion, commonly result from trauma.
Mainly recognized in DM Pt..
The bladder continues to fill and becomes greatly distended, and overflow incontinence occurs. The bladder is not contracted forcefully at any time. Because of sensory loss the patient feels no discomfort.

28. Medical management: Prevention of overdistention of the bladder
Emptying the bladder frequently and completely
Maintaining urine sterility with no stone formation
Maintain adequate bladder capacity without reflux
Pharmacological therapy: Parasympathomimetic medication (Urecholine)
Surgical management: to correct bladder neck contractures or vesicoureteral reflux, perfoming some type of urinary diversions procedures

29. Catheterization (1585)
Is the introduction of the catheter through the urethra into the bladder for the purpose of withdrawing urine.
Indications:
relieve urinary tract retention,
monitor accurate urine output in critically ill patients,
promote urinary drainage,
prevent urinary leakage in patient with advance pressure ulcer,
obtain a sterile urine specimen,
emptying the bladder before, during, after surgery and before certain diagnostic procedure.

30. Types of catheters:
Indwelling urethral catheter (Folly’s catheter) is remains in the place for continuous drainage . Types (Double and triple lumen catheter).
Intermittent catheter: is used to drain the bladder for short time (5-10 min)
Suprapubic catheter: it is surgical inserted into the bladder through a small incision above the pubic area.

31. Nursing Management during catheterization:
Assessing the patient and the system:
Assessing for age-related complication: infection, elderly patient doesn’t exhibit the S/S of infection but any physical and mental changes should be considered and reported.
Minimizing trauma: using proper size, use lubricate, proper technique, and securing the catheter

32. Cont….
4. Bladder retraining after indwelling catheterization: chart 45-10).
place patient on timed voiding schedule usually every 2-3 hours
the patient instructed to void as scheduled
scan the bladder for residual urine
if more equal or more than100 ml straight catheter may inserted for complete bladder emptying.
5. Assisting with intermittent self catheterization every 4-6 hours and at bed time (or when ever needed)

33. 5. Prevent infection in the catheterized patient:
Cont…..
5. Prevent infection in the catheterized patient:
Use aseptic technique during insertion of the catheter
Use sterile closed urinary drainage system
Prevent contamination of the closed system: never disconnect the tubing, the drainage bag should not touch the floor
The bag and collecting tubing are changed if contamination occurs, if urine flow become obstructed, if tubing start to leak.
Clamp the urine drainage if you raised the system above the kidneys level
Ensure free flow of urine

34. Cont… Empty the collection bag frequently
Never irrigate the catheter routinely
Never disconnect the tubing to collect urine sample
Avoid routine catheter changes
Wash the perineal area with soap and water at least twice a day
Monitor the patient’s voiding when the catheter is removed. The patient must void within 8 hours
Instruct the patient to drink measure fluid fro 8 am- 10 pm and stop drinking after 10pm

35. Dialysis: Indications:
Is the process used to remove fluid and uremic waste products from the body when the kidneys are unable to do so.
Indications:
Acute dialysis: is indicated when there is a high and rising level of serum potassium, fluid overload, impeding pulmonary edema, increased acidosis, pericarditis, and sever confusion. May also used to remove toxin from the blood.
Chronic or maintenance dialysis: is indicated in ESRD, in the presence of uremic signs and symptoms affecting all the body systems ( nausea, vomiting, sever anorexia, increasing lethargy, mental confusion). Hyperkalemia, fluid overload not responsive to diuretics and fluid restriction.

36. Hemodialysis The objective of Hemodialysis are
to extract toxic nitrogenous substances from the blood
and to remove excess water.
Indicated for:
the patient who are acutely ill and require short-term dialysis (day to weak)
and for patient with ESRD who require long-term or permanent therapy.
A dialyzer or artificial kidney serves as a synthetic, semipermeable membrane.

37. Principles of Hemodialysis:
Diffusion principle: dialysate ( is a solution made up of all the important electrolytes in their ideal Extracellular concentrate.
Osmosis principle:
Ultrafiltration principle

38. Hemodialysis System

39. Preprocedure:
A predialysis assessment include: patient’s history and clinical findings, response to previous dialysis treatment, and laboratory results
Evaluates fluid balance before dialysis treatment so that corrective measures may be initiated at the beginning of the procedure: blood pressure, pulse, Wt, intake and output, tissue turgor, dry Wt or ideal WT

40. Procedure: .. Check the equipment
Access to the circulation is gained by inserting two large gauge needles to a graft or fistula
Blood being to flow through the tubing, assisted by the blood pump
A clamped saline bag always is attached to the circuit, just before the blood pump to use it if hypotension occurred
Heparin infusion can be attached to the circuit

41. Cont…
Blood flows into the compartment of the dialyzer, where exchange of fluid and waste products takes place
Blood leaving the dialyzer passes through an air detector that shuts down the blood pump if any air is detected
After the located time finished, dialysis is terminated by clamping off blood from the patient, opening the saline line, and rinsing the circuit to return the patient’s blood
The nurse should monitor, support, assessing, and educating the patients.

42. Vascular Access:
Subclavian, internal Juglar, and femoral catheter (venous catheter)
Arteriovenous Fistula: created surgically, provide long-term access for hemodialysis, the fistula takes 4-6 weeks to mature before it is ready for use, the patient instructed to perform exercise to increase the size of these vessels, venipunctures is contraindicated in the arm with fistula, assess for the thrill.

43. 3. Synthetic graft:
An arteriovenous graft can be created by subcutaneously interposing a biological, semibiologic, or synthetic graft material between an artery and vein
The graft is created when the patient’s vessels are not suitable for a fistula ( DM)
Graft usualy placed in the forearm, upper arm, or upper thigh
Complication such as thrombosis, infection, aneurysm formation and stenosis at the site of anastomosis are more frequent than fistula

44. Hemodialysis Catheter

45. Internal Arteriovenous Fistula and Graft

46. Complication of Hemodialysis:
Atherosclerotic cardiovascular disease an, Angina and fatigue
Disturbance of lipid metabolism (hypertriglyceridemia)
Stroke
Peripheral vascular insufficiency
Gastric ulcer
Disturbed calcium metabolism that lead to bone pain and fractures

47. Cont…
Sleep problem
Fluid overload, malnutrition, infection, neuropathy and pruritis
Hypotension, nausea, vomiting, Dysrhythmias, chest pain
Painful muscle cramping
Air embolism
Dialysis disequilibrium result from cerebral fluid shift ( headache, nausea, vomiting, restlessness, decrease level of consciousness and seizures

48. Long term management for Hemodialysis:
Pharmacologic therapy: the dosage of medications need to adjust for patient undergoing hemodialysis and monitored closely to ensure that blood and tissue levels of these medications are maintained without toxic accumulation.
Example are antihypertensive medication which should not be taking at the day of dialysis to prevent hypotension.
II. Nutritional and fluid therapy:
To minimize uremic symptoms and fluid and electrolyte imbalances.
To maintain good nutrition status through adequate protein calories, vitamin, and minerals intake

49. Sodium is usually restricted to 2-3 g/day
Cont…..
3. To enable patient to eat a palatable and enjoyable diet.
Protein intake should be restricted to about 1 g/kg ideal body wt/day, High biologic quality protein ( contain essential amino acids) should be taken ( eggs, milk, meat, poultry, and fish)
Sodium is usually restricted to 2-3 g/day
Fluids are restricted to amount equal to the urine output plus 500ml to keep interdialytic wt gain under 1.5 kg.
Potassium restriction ( Average 1.5 to 2.5 g/day).

50. Nursing Management of the Hospitalized Patient on Dialysis
Protect vascular access; assess site for patency and signs of potential infection, and do not use it for blood pressure or blood draws
Monitor fluid balance indicators and monitor IV therapy carefully; keep accurate I&O and IV administration pump records
Assess for signs and symptoms of uremia and electrolyte imbalance; regularly check lab data
Monitor cardiac and respiratory status carefully
Monitor blood pressure; antihypertensive agents must be held on dialysis days to avoid hypotension

51. Address pain and discomfort
Cont……..
Monitor all medications and medication dosages carefully; avoid medications containing potassium and magnesium
Address pain and discomfort
Implement stringent infection control measures
Monitor dietary sodium, potassium, protein, and fluid; address individual nutritional needs
Provide skin care: prevent pruritus; keep skin clean and well moisturized; trim nails and avoid scratching

52. Nursing Management:
I. Meeting psychosocial needs: Give the patient and their Families the opportunity to express feelings of anger and concern over the limitations that disease and treatment impose.
Treatment of depression with antidepressant agents
Referring the pt and family to clinical nurse specialists, and psychologist
Assess noncompliant pt for the impact of renal failure and it’s treatment on the pt and family and the coping strategies that may use
Helps pt to identify safe, effective coping strategies to cope with ever-present problems and fears

53. Cont… II. Teaching patient self care:
III. Teaching patient about Hemodialysis
IV. Continuing care.
The five E’s: Bridges to Renal rehabilitation:
Encouragement,
Education,
Exercise,
Employment, and
Evaluation

54. Peritoneal Dialysis:
The goals are to remove toxic substances and metabolic wastes and to reestablish normal fluid and electrolyte balance.
May be treatment of choice for:
Patient with renal failure who are unable or unwilling to undergo hemodialysis or renal transplantation.
An initial treatment for renal failure while patient is being evaluated for a hemodialysis program, or when access to the blood stream is not possible

55. Cont…
3. Patient who are susceptible to the rapid fluid, electrolyte, and metabolic changes that occur during hemodialysis ( pt with DM, Cardiovascular diseases, older patients, and those who may be at risk for adverse effects of systemic heparin).
4. Pt with sever hypertension, congestive heart failure, and pulmonary edema ( not responsive to usual treatment regimens)

56. Peritoneal Dialysis

57. Peritoneal Dialysis (cont.)

58. Principles underlying peritoneal dialysis:
In peritoneal dialysis, the peritoneal serves as the semi permeable membrane ( provide about 22,000 square cm surface area)
Sterile dialysate fluid is introduced into the peritoneal cavity through an abdominal catheter at intervals.
Urea, creatinine, metabolic end products are cleared from the body by diffusion and osmosis

59. Cont…
It is usually takes hours to achieve with peritoneal dialysis what hemodialysis achieve in 6-8 hours
Urea is cleared at rate of ml/min where creatinine is removed more slowly
Ultrafiltration (water removal) occurs in peritoneal dialysis through an osmotic gradient created by using a dialysate fluid with dextrose concentration.

60. Preprocedure:
Prepare the patient for catheter insertion and the dialysis procedure by giving a thorough explanation of the procedure
Consent form may be signed according to hospital policy
Assess the pt’s anxiety, and provide support instruction
Take the pat’s history, identifying abdominal surgery or trauma
Examine the abdomen before the catheter is inserted.
Ask the patient to empty the bladder and bowel just before the procedure to avoid accidental puncture with the trocar
Give a preoperative medication, as ordered, to enhance relaxation during the procedure

61. Broad spectrum antibiotic agent may be given to prevent infection
Cont………..
Broad spectrum antibiotic agent may be given to prevent infection
Take and record baseline vital signs and body wt
Warm the dialyzing fluid to body temperature or slightly warmer to prevent hypothermia, increase urea clearance, prevent abd pain, and dilate the vessels of the peritoneum.
Prepare the proper concentration of dialysate and the medication to be added ( Heparin, Potassium chloride, antibiotic, and insulin may be added) as doctor order

62. Cont…
Immediately before initiating the dialysis, the nurse assembles the administrating set and tubing. The tube is filled with the prepared dialysate to reduce the amount of air entering the peritoneal cavity.
Preparation of equipment:
Peritoneal dialysis administration set,
peritoneal dialysis catheter set,
Trocar set, and
medication such as heparin, local anesthesia, KCL, and broad spectrum antibiotics

63. Performing the exchange:
Peritoneal dialysis involves a series of exchanges or cycles. This cycle is repeated through the course of the dialysis which varies from hours
1. Infusion phase: the dialysate is infused by gravity into the peritoneum. Period about 5-10 min is usually required to infuse 2 L of fluid.
2. Dwell or equilibrium phase: is the time allows diffusion and osmosis to occur.
3. Drainage phase: the tube is unclamped and the solution drains from the peritoneal cavity by gravity through closed system. Usually completed in min. the drainage fluid is normally colorless or straw-colored and should not be cloudy

64. Cont…
The entire cycle (exchange) takes 1 to 4 hours, depending on the prescribed dwell time
The removal of excess water is achieved by using a hypertonic dialysate with a high dextrose concentration that creates an osmotic gradient (1.5%, 2.5% and 4.25% are available in several volumes from ml).

65. Postprocedure:
Maintain accurate records of intake and output, and weight
Monitor BP and pulse frequently. Orthostatic blood pressure changes, and increased pulse rate are valuable clues that help the nurse evaluate the pt’s volume status
Detect S/S of peritonitis early ( low-grade fever, diffuse abd pain, rebound tenderness, and cloudy peritoneal fluid)
Maintain sterility of the peritoneal system
Detect and correct technical difficulties early

66. Assess for the presence of complications
Cont….
Prevent constipation which decreases the clearance of waste product and cause the patient more discomfort
Assess for the presence of complications
Peritonitis ( inflammation of the peritoneum) : most common
Leakage:
Bleeding
Long-term complications: abdominal hernia, hypertriglyceridemia, cardiovascular diseases, low back pain, and anorexia

67. Management of patients with urinary disorders (Chap.45)

68. Infection of the urinary Tract (UTI):
Caused by pathogenic microorganism in the urinary tract.
Lower tract infection ( Urethritis, prostatitis, and Cystitis)
Upper tract infection (pyelonephritis, interstitial nephritis and renal abscesses)
Other classification: Complicated and uncomplicated lower or upper tract infection

69. Lower Urinary tract infections: …
Pathophysiology: for infection to occur
bacteria must gain access to the bladder,
attach to and colonize the epithelium of the urinary tract to avoid being washed out with voiding,
evade host defense mechanisms, and initiate inflammation
Most UTI’s results from
fecal organism
Reflux: Urethrovesical reflux ( backward flow of urine from the urethra into the bladder

70. Cont…
Uropathogenic bacteria: Bacteriuria is generally defined as more than 100,000 colonies of bacteria per ml of urine
Most frequent bacteria responsible for UTI are those normally found in the lower GI tract such as E.coli , and lees common staphylococcus.

71. Routes of infection: Risk factors:
Up the urethra: ascending infection ( most common route)
Through the blood stream (hematogenous spread).
By means of a fistula from the intestine ( direct extension)
Risk factors:
Inability or failure to empty the bladder completely
Obstructed urinary flow
Decrease natural host defense or immunosuppression
Instrumentation of the urinary tract
Inflammation or abrasion of the urethral mucosa
Contributing conditions : DM, pregnancy, neurological disorders, gout.

72. Clinical manifestations:
about half patient with Bacteriuria have no symptoms.
Uncomplicated:
pain and burning on urination,
frequency,
urgency, nocturia, incontinence,
Suprapubic or pelvic pain,
and Hematuria with low back pain may presented
Complicated UTI: manifestations may range from asymptomatic bacteriuria to a gram-negative sepsis with shock

73. Assessment and Diagnostic findings:
Colony count: at least 100,000 colony per ml of urine on a clean catch midstream or cathetarized specimen is a major criterion for infection
Cellular studies: microscopic hematuria ( greater than 4 RBC’s per high power field, Pyuria ( greater than 4 WBC’s per high power field)
Urine culture: urine culture remains the gold standard in documenting a UTI and can Identify the specific organism present

74. 1. A cute pharmacologic therapy:
Medical management:
1. A cute pharmacologic therapy:
single dose administration, short course (3-4 days) medication regimen, or 7-10 day therapeutic course used in treating uncomplicated lower UTI.
2. Long term pharmacologic therapy:
If infection reoccurs within 2 weeks after completing antimicrobial therapy, another short course of full-dose antimicrobial therapy, followed by a regular bedtime dose of an antimicrobial agent be prescribed
If there is no recurrence, medication may taken every other night for 6-7 months

75. Cont… Patient education include:
1. Hygiene (shower rather than bathe tube
2. Fluid intake: drink enough fluid, avoid coffee, tea, colas, alcohol
3. Voiding Habits: void every 2-3 hours, void immediately after sexual intercourse
4. therapy: take medication exactly as prescribed, if recurrence take long term treatment

76. Upper UTI
Acute pyelonephritis: is bacterial infection of the renal pelvis, tubules, and interstitial tissue of one or both kidneys
Upper UTI is associated with the antibody coating of the bacteria in the urine
Pathophysiology:
Ascending of bacteria from the urethra, then to bladder to reach the kidney
Rarely from the blood ( less than 3%)
Ureterovesical reflux
Urinary tract obstruction, bladder tumor, strictures, benign prostatic hyperplasia, and urinary stones

77. Clinical manifestation: Acutely ill with chills and fever,
Cont…..
Usually these pt has enlarged kidneys with interstitial infiltration of inflammatory cells which may lead to destruction and atrophy of the kidney
Clinical manifestation:
Acutely ill with chills and fever,
leukocytosis,
Bacteriuria and Pyuria,
Flank pain.
Dysuria and frequency may associated.
Assessment and Diagnostic findings: US, CT scan to locate any obstruction, urine culture and sensitivity may performed

78. Medical management:
patient usually treated as outpatient if they are not dehydrated, not experiencing nausea or vomiting and not showing S/S of sepsis
For outpatient, a 2-weeks course of antibiotic is recommended , 6 weeks therapy may needed if relapse is seen, follow up urine culture is done 2 weeks after completion of antibiotic therapy

79. 2. Chronic pyelonephritis:
Repeated of a cute pyelonephritis may lead to chronic pyelonephritis
Clinical manifestations: usually no symptoms of infection, S/S may include fatigue, headache, poor appetite, polyuria, excessive thirst, and weight loss
Persistent and recurring infection may produce progressive scaring of the kidney, with renal failure as the end result
Assessment and diagnostic findings: Intravenous urogram, Measurement of creatinine clearance, BUN and creatinine levels, and urine culture

80. Complication: ESRF, hypertension, and formation of kidney stones
Medical management: Antibiotics depends on U/C, careful monitoring of renal function is important while giving medication due to the alteration of kidney function
Nursing Management: Monitor I&O, encourage fluid(3-4 L/day) unless contraindicated, Assess Temp. every 4 hrs, administer antibiotic as prescribed,Teach the pt the preventive measures of UTI

81. Acute Renal Failure: Categories of ARF: Mnifestations:
Is a sudden and almost complete loss of kidney function ( decreased GFR)
Mnifestations:
Oligurea
Anurea
normal urine volume.
Categories of ARF:
Prerenal: as a result of impaired blood flow to the kidney
Interrenal: as a result of actual parenchymal damage to the glomeruli and kidney tubule.
Post renal: as a result of obstruction somewhere distal to the kidney, such as Ureterovesical reflux.

82. Phases of ARF: Initial period: begins with initial insult
The oliguria period( less than 400ml/day): Characterized by increase serum urea, creatinine, K, uric acid, organic acids, and magnesium. The uremic symptoms first appears which is life-threatening such as Hyperkalemia.
The diuresis period: gradually increasing urine output, lab values stop rising and start to decrease
The recovery period: signals the improvement of renal function and may take 3-12 months, lab results return to the normal levels

83. Clinical manifestations:
Oliguria, anuria (less than 50 ml/day), or normal urine output are not as common.
Increased serum creatinine, and BUN level
Pt may appear critically ill and lethargic, with nausea, vomiting, and diarrhea.
Skin and mucous membrane are dry from dehydration and the breath may have the odor of the urine (uremic fetor)
Drowsiness, headache, muscle twitching, and seizures

84. Assessment and diagnostic findings:
Changes in the urine
Changes in the kidney contour ( ultrasound)
Increase BUN and creatinine levels
Hyperkalemia, hypocalcemia, hyperphosphoremia
Anemia
Metabolic acidosis

85. Medical management: Manage fluid and electrolyte imbalance
Diuretics may be given
Adequate blood flow to the kidney ( by low doses of dopamine 1-3 microgram/kg)
Dialysis may be initiated to prevent serious complications of ARF
Treat Hyperkalemia:
administer Kayexalate ( orally or by retention edema)
intravenouse glucose and insulin or calcium gluconate
sodium bicharbonate to elevate plasma PH which cause potassium to move into the cell.
Finally decrease the dietary intake of potassium
Correction of Acidosis and elevated phosphorus level ( by aluminum hydroxide---- phosphate binding agent)
Nutritional therapy

86. Nursing Management Monitor fluid and electrolyte balance
Reduce metabolic rate
Promote pulmonary function
Prevent infection
Provide skin care
Provide support

87. Chronic renal failure:
Or ESRD is a progressive irreversible deterioration in renal function in which the body’s ability to maintain metabolic and fluid and electrolyte balance fails, resulting in uremia or azotemia ( retention of urea and other nitrogenous wastes in the blood)
May caused by systemic disease such as DM, hypertension, chronic glomerulonephritis… etc

88. Clinical manifestations:
Neurologic: Weakness, fatigue, confusion, inability to concentrate, tremors, seizures, behavior changes
Integumentary: gray-bronze color skin, dry, pruritis, ecchymosis, thin brittle nails
Cardiovascular: hypertension, pitting edema, periorbital edema, pericardial friction rub, engorged neck veins, pericarditis, pericardial effusion, hyperkalemia, hyperlipidemia
Pulmonary: signs of pulmonary edema
Gastrointestinal: Ammonia odor to breath, mouth ulceration and bleeding, anorexia, constipation or diarrhea
Hematology: anemia
Musculoskeletal: muscle cramps, loss of muscle strength, bone pain, bone fracture

89. Assessment and diagnostic findings
GFR: by obtaining a 24 hr urine collection for creatinine clearance.
Na and water retention
Acidosis
Anemia
Ca and Ph imbalance
Complications:
Hyperkalemia
Hypertension
anemia, Bone disease

90. Medical management:
Antacids: To treat hyperphosphatemia and hypocalcemia (Aluminum-based antiacide bind with phosphorus in the GI tract)
antihypertensive cardiovascular agents
Antiseizure agents
Erythropoietin
Nutritional therapy
Dialysis